Medication	Dosage	Treatment considerations	Adverse effects
Nonbiologics
Methotrexate (FDA approved in 1972)	Starting dose: 7.5 mg; therapeutic dose: 15 mg; maximum dose: 30 mg once per week orally, subcutaneously, intramuscularly, or intravenously May give divided doses orally twice per day 3 times per week (for decreased gastrointestinal adverse effects) Start with 2.5- to 5-mg doses for those with possible drug interactions, kidney disease, or diabetes mellitus	1 mg of folic acid supplementation is recommended once per day except on days when taking methotrexate (decreases gastrointestinal and liver abnormalities) Cost is significantly less than tumor necrosis factor-alpha inhibitors Avoid in alcohol use disorder and liver disease Avoid if any known bone marrow suppression or immunodeficiency syndromes Avoid if abnormal baseline kidney and liver function	Common: anorexia, fatigue, increased risk of infection (including reactivation of latent tuberculosis, hepatitis B and C, or Epstein-Barr virus), liver enzyme elevation, nausea, stomatitis Rare: B cell lymphoma, cirrhosis, hemorrhagic enteritis, nephrotoxicity, pancytopenia, pneumonitis, Steven-Johnson syndrome/toxic epidermal necrolysis
Apremilast (Otezla; FDA approved in 2014)	30 mg orally twice per day Initial dose: 10 mg once per day, titrated up by 10 mg per day over first 5 days If glomerular filtration rate is < 30 mL per minute per 1.73 m2, decrease to 30 mg once per day to prevent adverse effects or toxicity	Effective for scalp, palmar, and plantar involvement and psoriatic arthritis No strong evidence for concurrent use of systemic treatments or phototherapy Consider discontinuation if > 5% weight loss Avoid concurrent use of cytochrome P450 inducers, which will decrease effectiveness	Common: diarrhea, nasopharyngitis, nausea, tension headache; upper respiratory tract infection, 70% to 80% of gastrointestinal adverse effects occurred within the first 2 weeks and 60% to 65% resolved after the first month Rare: angioedema, depression, suicidal ideation
Cyclosporine (FDA approved in 1997)	2.5 to 4 mg per kg orally, in divided doses twice per day, for 12 to 16 weeks Start 2.5 mg per kg per day and increase by 0.5 mg per kg per day every 2 weeks to a maximum dose of 4 mg per kg per day Discontinue if inadequate improvement at maximum dose for 6 weeks	Rapid control of severe, recalcitrant disease, acute flare-ups, and erythroderma; can be used for bridge therapy until safer long-term treatment can be found Relapse common after discontinuation Avoid phototherapy when taking cyclosporine because it increases the risk of photocarcinogenesis (sequential use is effective and safer) Do not use with statins, thiazide and potassium sparing diuretics, warfarin, or nonsteroidal anti-inflammatory drugs due to increased risk of adverse effects Not used as long-term treatment due to multiple serious adverse effects	Common: headache, hypertension (if hypertension develops, decrease dose; if it does not normalize, stop medication), musculoskeletal pain, nephrotoxicity (19% to 24% will develop reversible impairment with short-term treatment), paresthesia Rare: kidney fibrosis and irreversible nephrotoxicity (increased risk if treatment duration is > 2 years)
Acitretin (FDA approved in 1997)	25 to 50 mg orally once per day with food Can take 36 months for full treatment response	Combined with phototherapy, it is more effective than monotherapy Not immunosuppressive, can be used in those with HIV Avoid in severe kidney or liver disease	Common: brittle nails, cheilitis, dry eye, epistaxis, hair loss (at doses > 17.5 mg per day in women), hyperlipidemia (25% to 50%), itching/burning skin, xerosis Rare: capillary leak syndrome, exfoliative dermatitis, hepato-toxicity, hypervitaminosis A syndrome, pseudotumor cerebri, thromboembolism
Deucravacitinib (Sotyktu; FDA approved for adults only in 2022)	6 mg orally once per day	Screen for and treat tuberculosis before starting If liver function test result is three times the upper limit of normal, evaluate for drug-induced liver injury Not recommended for patients with active hepatitis B or C	Common: infection, liver enzyme and triglyceride elevation Rare: increased risk of lymphoma, rhabdomyolysis
Biologics
Adalimumab (FDA approved in 2005 for adults with psoriatic arthritis and in 2008 for severe plaque psoriasis)	80 mg subcutaneously on day 1, then 40 mg on day 8, and continue 40 mg once every 2 weeks for maintenance	Used with acitretin and methotrexate (5 to 15 mg per week), it is safe and increases long-term effectiveness Do not use in patients with active infection, history of lymphoreticular malignancy, New York Heart Association class III or IV congestive heart failure, or untreated hepatitis B infection	FDA boxed warning: serious infection risk (i.e., opportunistic infections, including tuberculosis and invasive fungal infections) and malignancy risk (i.e., lymphoma and skin cancer) Common: diarrhea, fever, injection site reaction, pruritus, rash, upper respiratory tract infection, urticaria Rare: exacerbation or new onset of congestive heart failure, drug-induced reversible lupus, or interstitial lung disease
Etanercept (FDA approved in 2004 for adults and children older than 4 years with moderate to severe plaque, scalp, or nail psoriasis, or psoriatic arthritis)	50 mg subcutaneously once per week or 25 mg subcutaneously twice per week (72 to 96 hours apart) For severe chronic plaque psoriasis, start 50 mg subcutaneously twice per week for 3 months, then decrease to 50 mg once per week Patients 4 to 17 years of age: 0.8 mg per kg per dose once per week for < 63 kg and 50 mg once per week if ≥ 63 kg	Can be used with topical agents, methotrexate, and acitretin (decreased risk of cutaneous squamous cell carcinoma when used with acitretin) Do not use in patients with untreated hepatitis B infection, history of lymphoreticular malignancy, active infection, or New York Heart Association class III or IV congestive heart failure	FDA boxed warning: serious infection risk (i.e., opportunistic infections, including tuberculosis and invasive fungal infections) and malignancy risk (i.e., lymphoma and skin cancer) Common: diarrhea, fever, injection site reaction, pruritus, rash, upper respiratory tract infection, urticaria Rare: exacerbation or new onset of congestive heart failure, drug-induced reversible lupus, or interstitial lung disease
Infliximab (FDA approved in 2005 for adults with psoriatic arthritis and in 2006 for severe plaque psoriasis)	5 mg per kg per dose intravenously once every 8 weeks (initially, and if there is a break in treatment, 5 mg per kg per dose on weeks 0, 2, and 6) Increase in the risk of infusion reactions and loss of effectiveness if > 8 weeks between infusions due to antibodies to infliximab	Can be used with topicals, acitretin, or methotrexate for synergistic effect Do not use in patients with active infection, history of lymphoreticular malignancy, New York Heart Association class III or IV congestive heart failure, or untreated hepatitis B infection	FDA boxed warning: serious infection risk (i.e., opportunistic infections, including tuberculosis and invasive fungal infections) and malignancy risk (i.e., lymphoma and skin cancer) Common: diarrhea, fever, injection site reaction, pruritus, rash, upper respiratory tract infection, urticaria Rare: exacerbation or new onset of congestive heart failure, drug-induced reversible lupus, or interstitial lung disease
Ixekizumab (Taltz; FDA approved in 2016 for plaque psoriasis, 2017 for psoriatic arthritis, 2020 for pediatric plaque psoriasis)	Plaque psoriasis Adults: 160 mg subcutaneously the first week, then 80 mg subcutaneously every 2 weeks through week 12, then 80 mg every 4 weeks Children (6 to 17 years of age): < 25 kg: 20 mg subcutaneously every 4 weeks, then start 40 mg subcutaneously once per week 25 to 50 kg: 40 mg subcutaneously every 4 weeks, then start 80 mg subcutaneously once per week > 50 kg: 80 mg subcutaneously every 4 weeks, then start 160 mg subcutaneously once per week Psoriatic arthritis Adults: 80 mg subcutaneously every 4 weeks after starting dose of 160 mg subcutaneously the first week	Avoid in patients with history of or active inflammatory bowel disease or tuberculosis infection	Common: injection site reaction, nausea, neutropenia, thrombocytopenia, tinea infections Rare: hypersensitivity reactions (e.g., anaphylaxis, angioedema), inflammatory bowel disease
Biologics
Secukinumab (Cosentyx; FDA approved in 2015 for adults with plaque psoriasis, in 2021 expanded to children and adults with plaque psoriasis, nail psoriasis, and psoriatic arthritis)	Plaque psoriasis/nail psoriasis Adults: 300 mg subcutaneously once every 4 weeks (loading dose of 300 mg once per week for 5 weeks) Children (6 to 17 years of age): < 50 kg: 75 mg* ≥ 50 kg: 150 mg* Psoriatic arthritis Adults: 150 mg subcutaneously once every 4 weeks (loading dose: 150 mg once per week for 5 weeks) Children (2 to 17 years of age): 15 to 50 kg: 75 mg* > 50 kg: 150 mg*	Avoid in patients with history of or active inflammatory bowel disease or tuberculosis infection Shown to be superior to phototherapy in patients with new-onset, moderate to severe plaque psoriasis; the high and sustained skin clearance observed indicates that biologic treatment for psoriasis may be more effective if used early in the disease course	Common: diarrhea, infection, nasopharyngitis, neutropenia, upper respiratory tract infection Rare: hypersensitivity reactions (e.g., anaphylaxis, angioedema), inflammatory bowel disease, mucocutaneous Candida infections, sepsis, toxic shock syndrome
Ustekinumab (Stelara; FDA approved for psoriatic arthritis and plaque psoriasis in adults and children 6 to 17 years of age)	Adults < 100 kg: 45 mg subcutaneously every 12 weeks (45 mg subcutaneously on weeks 0, 4, and 12 to start) Adults ≥ 100 kg: 90 mg subcutaneously every 12 weeks (90 mg subcutaneously on weeks 0, 4, and 12 to start) Children 6 to 17 years of age < 60 kg: 0.75 mg per kg per dose subcutaneously every 12 weeks (0.75 mg per kg per dose on week 0, 4, 12 to start) Children 6 to 17 years of age ≥ 60 kg: 45 mg subcutaneously at 0 and 4 weeks, then 45 mg subcutaneously every 12 weeks	Can be used with acitretin, methotrexate, apremilast, and cyclosporine for synergistic effects Using with methotrexate leads to longer drug survival in biologic-naive patients Avoid in patients with untreated hepatitis B or history of lymphoreticular malignancy, active infection, or	Common: abdominal pain, arthralgias, back pain, diarrhea, fatigue, headache, infection, injection site reaction, mouth or throat pain, pruritus Rare: hypersensitivity reactions (e.g., anaphylaxis, angioedema), malignancy, pneumonia (i.e., interstitial, eosinophilic, or cryptogenic organizing), posterior reversible encephalopathy syndrome